The Hidden Health Care Workforce: Recognizing, Understanding and Improving the Allied and Auxiliary Workforce

Allied and auxiliary health care workers make up over 60 percent of the nation's 10.5 million-person health care workforce. These workers, ranging from physical therapists and technicians at the allied level to unlicensed assistive personnel and custodial workers at the auxiliary level, play critical support roles in the health care system. Any significant reform in the way health care is delivered will mean a change in how these individuals are trained and utilized. Yet, employers and researchers have often overlooked their contributions and their concerns.

The California Twenty-First Century Workforce Project represents a comprehensive examination of the supply and distribution of allied and auxiliary health care workers, the educational system that readies these workers for careers, and the pressures that California's dynamic managed care environment exert on them. With funding from the California HealthCare Foundation, the Workforce Project was conducted by the University of California San Francisco, Center for the Health Professions in conjunction with Charles R. Drew University of Medicine and Sciences, College of Allied Health. The Project's examination consisted of reviewing pertinent literature, collecting demographic data on California's health care workforce, and conducting qualitative surveys, interviews and focus groups throughout the state. The study finds an allied and auxiliary workforce suffering from high rates of turnover, ill-defined expectations, low pay and inadequate training. Three contributing factors to these issues are identified:

Care delivery organizations are struggling to survive in California's competitive health care market as pressures to control costs, satisfy consumers, and improve quality have transformed the way in which care must now be delivered.

Workers are being asked to become more flexible, more tolerant of uncertainty and more capable team members. The era when workers remained with one institution through an entire career is over.

Educators are having difficulties preparing future workers with appropriate skills for their new roles. They are confronted with numerous challenges at a time when the skill sets of young people graduating from California high schools and colleges are eroding.

Although the future of allied and auxiliary workers depends on these three constituencies, care delivery organizations, workers, and educators have set policies in isolation from one another. The overriding challenge of the next decade will be to build partnerships among these constituencies that allow institutions to create new approaches to health care that contain cost, increase quality and improve consumer satisfaction, while integrating the allied and auxiliary workforces into those new approaches, by cultivating their skills, creativity, loyalty and motivation.

The Workforce Project has identified seven themes that permeate the challenge of reinventing the allied and auxiliary workforce. The themes and the related findings are:

1. New Divisions of Labor
To meet immediate demands of reducing costs and increasing productivity, employers are transferring work to the least costly provider and creating a more flexible, multifunctional workforce. These trends can be challenging and disruptive to workers, and their efficacy has not always been established with outcomes data.

2. Lower Pay With More Responsibility
Limiting benefits and wages represent key vehicles for cost reduction. For some of the most highly skilled professions, wage rates have kept pace or sometimes exceeded rates of inflation. Yet, for other allied and auxiliary occupations, particularly at the entry level, wages have remained flat or decreased.

3. The Struggle to Attract and Retain Quality Workforce
Employers struggle to attract, retain and promote a skilled workforce. At all levels, employers have difficulty attracting workers with critical thinking, communication and computer skills as well as a strong work ethic. While turnover rates are problematic and many current and future labor shortages were identified, few leaders in human resources departments are addressing these challenges with long-term solutions.

4. The Need to Tie Human Resources to a Quality Strategy
At a time when many health care delivery institutions and systems are recognizing the need to compete on the basis of quality, few organizations offer a human resources initiative tied to a quality strategy. This requires investments in all members of the health care organization - not just the highest paid managers or clinicians - and an understanding of the importance of a committed workforce to delivering high quality care.

5. Regulatory and Oversight Inconsistency
Regulatory standards that guide the practice of allied and auxiliary workers are disconnected from the realities of the modern care delivery system. Out-of-date accreditation and licensure standards that do not reflect modern care delivery nor quality improvement principles have gone unchallenged.

6. A Widening Gap Between Education and the Needs of Industry
The educational system has not offered a product that meets the needs of the care delivery system or students seeking careers in allied or auxiliary positions. Employers cite increasing skill deficits in their workforce, including technical and computer skills, critical thinking, communication, management, delegation, supervision skills and an orientation to a systems perspective. Recent graduates of allied health programs cite similar skill deficits in their preparation for modern health care careers.

7. The Changing Nature of Work and Career Advancement
The fundamental meaning of 'work' is changing in the post-industrial, service-oriented economy. At all levels - individual, organization and market - change appears to be a constant characteristic, and workers increasingly find that the skills with which they were formally trained are becoming obsolete.

RECOMMENDATIONS

The challenges that the Project highlights are caused in large part because of the divisions between care delivery, education, labor unions and the workforce itself. The following recommendations propose the use of partnerships among these sectors to address specific issues as well as the collection of data to evaluate the outcomes of these partnerships and recommended actions.

Recommendation 1. Define skill requirements that are aligned with care delivery standards, reflecting both general employment skills and core clinical and technical competencies, for the allied and auxiliary health care workforce. Require health training programs to meet these skill requirements and standards as part of their accountability to students and the public.

Recommendation 2. Expand training and awareness to better prepare the workforce to deliver health care to an increasingly multicultural society. First, define and develop competencies for delivering culturally sensitive care for all allied and auxiliary workers. Second, actively support hiring and training a more diverse workforce.

Recommendation 3. Create new types of health services work environments in which care delivery organizations are committed to high quality, flexibility, service orientation and cultural diversity. Improve conditions of employment in order to sustain the new types of work environments.

Recommendation 4. Position the allied and auxiliary workforce in health care delivery's strategic process of improving the quality of patient care.

Recommendation 5. Build new participatory structures that involve labor, education, and the allied and auxiliary workforce in change and quality improvement processes.

Recommendation 6. Encourage allied and auxiliary health care workers to take advantage of career enhancement opportunities to develop and expand their skills in the rapidly changing health care environment.

Recommendation 7. Improve regulation of professions, occupations and health care facilities in order to align the training and use of allied and auxiliary workers with the needs of care delivery. Allow allied and auxiliary workers to practice effectively and to their full capabilities.

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